Travel sick - banning smoking in cars

Queuing in traffic around the north circular on the way to relatives was a feature of my childhood. As was my mother's stress at the combination of the length of the journey and my father's nose to tail break hard driving. Her need for a cigarette was pretty overpowering. I remember my brothers and I pleading with both our (health professional) parents not to smoke in the car - something they heeded as best as nicotine addicts can. We had to have the windows wound up to shut out the smell of traffic fumes only to be locked in the car with cigarette fumes. It was only the very real threat of me throwing up due to aforesaid breaking that stopped my mother lighting up.

This experience was probably pretty common in the 1970s and increasingly less common in the decades since - although Labour and co-operative MP Luciana Berger claims here that one in five children may still be exposed to smoke in cars. Whether it is out of ignorance of the harm they do or denial in the face of addiction, only legislation will force parents to confront what they are risking.

It's hard to know why banning smoking in cars is such a contentious issue. Yet it's a real fight - one that may well go down to the wire - just like banning smoking in public places - but we got there in the end with that. We have to hope that this government doesn't once again run scared of legislation to protect the public's health just as it did with plain packaging of cigarettes and minimum unit pricing of alcohol - although it may be tiptoeing back to reconsider the latter.

The House of Lords has backed Labour's proposal to ban smoking in cars carrying children. Ministers are now looking at how to implement such a ban. Disappointingly, however, deputy prime minister Nick Clegg said on his weekly LBC phone in that he was opposed to legislation that would allow the government to ban smoking in cars with children - calling it 'sub contracting parenthood'. But then I hadn't realised that Clegg was a smoker. Does he think car seats for babies is 'sub contracting parenthood' or is it just the smoking thing? Read the story here
Read @COPDdoc Nick Hopkinson's excellent dissection of Clegg's arguments here


There is widespread evidence here and here that second hand smoke harms those who breathe it in. That this is so was a strong feature of the argument for banning smoking in public places - those employed in pubs and clubs were forced to breathe in the cigarette smoke of punters hour after hour. Five years after the public smoking ban, there were reports of improved health amongst barworkers and it has been almost universally welcomed by them and by their customers. Although there are still hardy knots of people gathered outside pubs and clubs sharing nicotine and camaradrie with other smokers.

It was thought that the ban on smoking in public places would drive smokers back into the home to light up. But it seems this didn't happen. Many smokers took the opportunity to give up whilst many more at least took their smoking outside just as they had to when in a public place.

Of course, public health education must continue to be a big part of changing smokers' habits, together with support to help people give up. But we know from experience that public health campaigns are most effective in changing behaviour when they are backed by legislation. That was the lesson from introducing the law on wearing seatbelts, and the drink driving and smoking bans.

Children, of course, have no say in any of this but if they had, I don't believe one would say 'I wish Mum or Dad would smoke in the car.'

Going up in smoke

At last! Smoking -or rather not smoking - is beginning to show health benefits in the here and now that are more tangible to your average smoker than scary warnings about cancer and heart disease in the distant future.

Two recent studies have reported on the benefits that not smoking is having on young people. One in Pediatrics reported a sharp fall in the number of children admitted to hospital with severe asthma, linking it to the smoke free legislation introduced in England. Whilst another study in the US published in the American Journal of Public Health reported on the effectiveness of smoke free air laws and state tobacco control programmes on preventing youth smoking in the US. 

Earlier studies reported on the benefits to bar staff that the smoking ban has brought - for example, reductions in respiratory illnesses whilst other studies have reported on the reduction of admission to hospital for acute coronary syndrome.

The asthma study found that in the first three years after the ban on smoking in public places, introduced in England 2007, the number of admissions to hospital for childhood asthma was down by 6,802. Before the implementation of the legislation, the admission rates for childhood asthma were going up by 2.2%. The results were the same for boys and girls regardless of whether they lived in towns or rural areas, whether they were poor or wealthy. A similar fall in Scotland, where the public ban was enforced a year earlier was reported in a previous study.

The study allays early fears that there would be an increase in smoking at home if people were not allowed to smoke in public places. In fact, the researchers from Imperial College in London said that it appeared  that more people are moving towards having smoke free homes instead.

Capitalising on these benefits is key if public health is to maintain some sort of momentum to reduce smoking and ideally prevent children taking up smoking in the first place.  In recent years it seems the twin challenges of obesity and alcohol have come to the front whilst anti –smoking has been pedalling furiously behind. 

But the recent scary TV advertising showing a tumour growing out of a cigarette and the launch of the Department of Health’s recent Quick Kit Campaign http://campaigns.dh.gov.uk/2012/11/09/quit-kit-campaign-2013/ should see the stop smoking agenda back on track. And not before time, as another study published in the New England Journal of Medicine into women and smoking reported a steep increase in the risk of women smokers dying from lung cancer – attributable to more women smoking and also a decrease in mortality amongst women who were non-smokers. 

As my grandfather (the first in four generations of doctors/nurses/midwives) might have said: the three greatest causes of death are: smoking, smoking and smoking.

References

Millet C, Tayu Lee J, Laverty A, Glantz S, Majeed A ; Hospital Admissions for Childhood Asthma After Smoke-Free Legislation in England Published online January 15 2013 pediatrics.aappublications.org/content/early/2013/01/15/peds.2012-2592.abstract

Farrelly MC, Loomis BR, Han B et al; A Comprehensive Examination of the Influence of State Tobacco Control Programs and Policies on Youth Smoking. Published online January 17 2013 Am J Public Health. http://www.ncbi.nlm.nih.gov/pubmed/23327252#

Thun MJ, Carter BD, Feskanich D, et al. 50-Year Trends in Smoking-Related Mortality in the United States. New England Journal of Medicine. Published online January 24 2013

Under water

You will remember when we were all flooded just recently (before the ice age struck). Well, I woke up to the sound of water dripping steadily. Sadly, it was not a burst of enthusiasm on the part of the shower but the bathroom ceiling that was spilling out. I touched the ceiling and realised I was standing under a giant sponge. Fortunately, I have the kind of neighbours who always ‘know somebody’ and they put me in touch with a friendly plumber who advised me to empty the water tank which lurks in the loft just to the side of the giant sponge and to stick a screwdriver into the ceiling to relieve the pressure of any water.

I did this in my best nurse lancing a boil manner (ie turned away in case anything hit me) but nothing gushed out, the water kept dripping and a bit of the ceiling came away, sodden and rotten.  A quick investigation in the narrow roof space (by nice plumber not yours truly – too many spiders) was that there was a leak in the roof that had been there for some years but someone had thoughtfully placed a washing up bowl under the leak and a few towels. As we have been in the house six years this was a bit mind boggling. However, I have been fortunate enough to find someone to repair the roof and a plasterer is due soon (no really) to repair the inside.

It did not escape me that I was lucky enough to fix this problem easily and although emptying a huge hot water tank was enough to make me cry (bad enough when it’s a house full of teenagers emptying it for you but to be pouring it away was criminal) but I knew I could afford to do so. I knew too that the damp built up over the years was fairly minimal and unlikely to have been harmful to our health (although it explains the mould that kept growing in the bathroom). 

Others are not so fortunate and damp is all too often a result of poverty caused by poor housing and a lack of heating. Damp leads to mould which can be associated with a range of breathing problems from wheezing to asthma, coughs as well as serious infections such as meningitis.

Nowhere is this brought home so profoundly as by the tragic story of baby Telan Stone featured in the Guardian in association with Joseph Rowntree Trust. http://www.guardian.co.uk/society/video/2012/nov/19/child-damp-temporary-housing-video

The Stone family lived in a one bedroom flat where the damp was bad enough for there to be fungus growing out of the walls. Whilst no direct connection has been made between the damp and Telan’s death, it is absolutely true that people should not be living in such conditions. The Stone family has since been rehoused. 

Six years ago the charity Shelter produced a report highlighting the impact that bad housing had on children’s health http://england.shelter.org.uk/__data/assets/pdf_file/0009/66429/Chance_of_a_Lifetime.pdf  In the report, Shelter recommended the building of affordable homes, doing more to help those on low incomes to stay in their homes, increasing resources to improve the quality of rented homes – both social and private - and called for a target deadline for overcrowding to be a thing of the past.  

 

All these recommendations were made six years ago and still, judging by the Guardian’s poverty series (http://www.guardian.co.uk/society/poverty) or reports from any number of charities, the problems are the same, if not worse now, with welfare cuts and housing benefit caps destroying an already wobbly infrastructure.

From a position of public health, the answer is mostly obvious. Start upstream. If the beginning is poverty, that is what needs to be addressed. Cutting benefits and dividing the world into deserving and undeserving does not solve the problems, it merely tries to cover them up.

It’s a bit like sticking a washing up bowl under a hole in the roof and hoping that the next occupants won’t notice the leak. Eventually it will cause damp, damage and potentially disaster which might not be put right so easily.

Reference

Marmot M, Wilkinson R, (eds) (2004) Social Determinants of Health, Oxford University Press